Objectives We previously reported inferior outcomes for locally-advanced head and neck squamous cell carcinoma (LAHNSCC) patients treated with concurrent cetuximab vs. inferior 4-year OS (86.9% vs. 70.2% vs. 40.9%; < .0001) and 4-year LRF (6.3% vs. 9.7% vs. 40.2%; < .0001). Late toxicity was highest with 5FU/carboplatin (25.0%) vs. cisplatin (8.0%) vs. cetuximab (7.7%). Conclusions Although 5FU/carboplatin patients were sicker and experienced greater toxicity than cisplatin patients, no significant difference was found in all endpoints. In contrast, despite similar pretreatment characteristics, outcomes for cetuximab vs. 5FU/carboplatin were significantly worse. We feel that caution should be used with routine use of cetuximab in the management of LAHNSCC. Introduction Treatment with chemoradiation is an accepted standard for locally advanced head and neck squamous cell carcinoma (LAHNSCC). The addition of concurrent chemotherapy to radiotherapy (RT) for LAHNSCC results in an absolute survival benefit of 6.5% at 5-years, with greater benefit with platinum-based chemotherapy [1]. Among the concurrent platinum agents, single-agent cisplatin is superior to single-agent carboplatin and equivalent to carbo-platin with 5-fluorouracil (5FU) in retrospective analyses [2,3]. Although chemoradiation with high-dose cisplatin improves survival versus RT alone, it is associated with higher toxicity [4]. Therefore less toxic agents that will achieve equivalent or superior outcomes have been sought. Bonner et al. reported that cetuximab/RT resulted in improved locoregional control and survival with little increase in toxicity compared with RT alone [5]. This led to the adoption of cetuximab as one alternative to cisplatin concurrent with RT for LAHNSCC. Although cisplatin is still the most commonly used agent (51%), cetuximab is being used CB-839 in approximately 20% of patients [6]. Importantly, the study by Bonner was conducted when RT alone was still an accepted standard for LAHNSCC. Only recently has cetuximab/RT been compared to concurrent platinum/RT in prospective randomized trials, although results are not yet reported. Our initial retrospective report showed that concurrent cisplatin/RT versus cetuximab/RT was associated with superior locoregional control, failure-free survival, and overall survival [7]. Nonetheless, unmeasured confounders limited this study. Prior to FDA approval of cetuximab for LAHNSCC, non-cisplatin candidates were routinely treated with alternative platinum-based regimens, namely, 5FU/carboplatin [8] at our center. We hypothesized that characteristics of these patient groups would be similar and hence we sought to compare the outcomes of concurrent IMRT with high-dose cisplatin, 5FU/carboplatin, or cetuximab. Methods and materials Study design In this Institutional Review Board-approved (WA0654-10) study, we retrospectively identified patients with a diagnosis of LAHNSCC of the oropharynx, hypopharynx, or larynx treated with curative intent with IMRT and concurrent cisplatin, 5FU/carboplatin, or cetuximab, from 11/02 to 4/08. Reasons for exclusion were surgery to the primary site, prior RT for a non-basal cell carcinoma of the head and neck, induction or adjuvant chemotherapy, weekly cisplatin, or prior active malignancy. Three hundred sixty patients were eligible for analysis. Comorbid conditions were scored using the Charlson criteria [9]. Alcohol use was defined as none/mild (7 drinks/week) versus moderate/heavy (>7 drinks/week). Smoking history was recorded as >10 or 10 pack-years. Creatinine clearance was calculated using the Cockcroft-Gault formula. Pretreatment Karnofsky performance status (KPS) was recorded CB-839 for all except two patients. Treatment Radiotherapy techniques have been previously described ATF1 [7,10]. Patients were treated with IMRT with a median dose of 70 Gy. Treatment with cisplatin and cetuximab was delivered as previously reported [7]. Patients treated with 5FU/carboplatin received a planned three cycles (carboplatin 70 mg/m2 and 5FU 600 mg/m2 daily continuous infusion, both for 4 days) every 3 weeks, with recycling time and dosing adjusted based on toxicity concerns. Patients in whom chemotherapy was switched CB-839 after one or two cycles (= 30; 24 cisplatin, 6 5FU/carboplatin, 0 cetuximab) were analyzed according to the initial prescribed drug regimen. Toxicity Acute/chronic toxicity was graded by chart review according to the Common Toxicity Criteria for Adverse Events CB-839 (CTCAE), v3. Duration of percutaneous endoscopic gastrostomy (PEG) dependence was measured from the time RT was completed. Late toxicity was defined as the presence of PEG or tracheostomy 12 months from RT start. Statistical methods Time to locoregional failure (LRF), distant metastasis (DM), or death was calculated from the first day of RT for all patients. OS was censored at the date of last information. The KaplanCMeier method was used to calculate OS. Univariate analysis was performed using a Cox proportional hazards model. Variables included sex, age, race, KPS, primary site of disease, T and N classification, Charlson.